Dental caries is a disease with several signs ranging from microscopic loss of inorganic crystalline (known as a hydroxyapatite), which is invisible to the human eye, to obvious cavitation. Dental caries is the result of demineralization (selective dissolving of Ca and P ions from said hydroxyapatite crystallines) of tooth enamel, dentin, or cementum initiated by an acid produced by oral bacteria. Over time, overt cavitation will occur unless the demineralized areas are remineralized (redeposition of Ca and P ions). Hence, caries is a bacterial disease and the treatment thereof should therefore primarily revolve around overcoming the infection. Today, there is a growing consensus that different types of carious lesions exist and that the management of the disease should depend on the severity of the carious lesion as well as the caries risk status of a patient.
In recent times the term “minimal intervention dentistry” has been coined to describe a new approach to the restoration of caries lesions. As mentioned previously, caries is a bacterial disease, so that treatment should revolve primarily around overcoming the infection. It is often possible to interrupt the process and actually heal the early lesions prior to cavitation of the surface of the crown of a tooth. If this action is too late or unsuccessful, and the enamel surface is damaged sufficiently to retain plaque, then some degree of surgical intervention will become necessary to restore the smooth surface once more. But it is suggested that any surgical intervention should be as minimally invasive as possible and should provide only for the removal of completely demineralized infected tooth structure. Remaining structure, particularly demineralized or caries-affected enamel and dentin, should be retained and remineralized wherever possible. This will lead to an extensive preservation of natural tooth structure and this, in turn, will minimize aesthetic problems and at least slow down the need for replacement dentistry.
The pattern of attack of a carious lesion and its progress through the enamel and dentin has been understood for many years, and has tended to dictate the treatment methods used. However, the purely surgical approach to caries control is now recognized as being far too destructive to be used as the first line of defense. It is relatively inefficient because it does not cure the disease, and the major problem is that it leads to a continuous process of replacement dentistry wherein the cavity just gets larger and the tooth gets weaker.
The greatest value lies in the restoration of a minimal new lesion so that its biological activities can be used to the maximum and it will not be exposed to undue occlusal load. The relatively low fracture strength may be regarded as a limitation but wear resistance improves considerably as the restoration matures. This means that as long as the restoration is well surrounded by sound tooth structure it can be placed on the occlusal surface with safety. However, if the proposed restoration is to be heavily loaded then a lamination technique will need to be utilized.
Different types of restorative materials and luting cements are currently used in daily dental practice. The most common are amalgam, composite resins, glass ionomers, dental casting alloys, and ceramics. Each material possesses advantages and disadvantages. Amalgam has a long history as a practical and relatively inexpensive restorative material and is still widely used. However, the toxicity controversy of the mercury is a disadvantage. Dental casting alloys have excellent physical properties, but the production process is costly and some components of the alloy may include allergic reactions in patients, such as the nickel element. Moreover, amalgam and casting alloys are not tooth colored and the demand for more aesthetic materials is increasing. Resin composites are the most aesthetically acceptable of the available restorative materials with satisfactory physical properties. However, allergic problems have arisen and some concern about the estrogenic effects of bisphenol A as an environmental hormone has been indicated. The glass ionomer cements are more aesthetically pleasing than metallic restoratives, although less so than resin composites, and are considered one of the safest restorative materials.
Glass ionomer cements have remained an important class of dental restorative materials for almost 30 years. In this role, their attributes include adhesion to untreated tooth mineral and the release of fluoride ions that are thought to confer resistance against dental caries.
Glass ionomer cements are probably more accurately and scientifically known as glass-polyalkenoate cements. They are a true acid-base material, where the base is an inorganic fluoroaluminosilicate glass with a high fluoride content and this interacts with an organic poly(alkenoate acid). Right after the mixing of these components, calcium polyacrylate chains from aluminum ions will begin to form aluminum polyacrylate chains to produce the polyacid matrix (salts) and these are less soluble and notably stronger. The final matrix formation then takes place. The use of glass ionomer materials in dentistry has expanded tremendously. In the past 20 years clinicians have accepted glass ionomer cements as a routine part of their operative dentistry armamentarium. During the same time period attempts were made to use glass ionomer materials, both restorative cements and more diluted materials, as sealants (R. Simonsen, J. Public Health Dent. 1996; 56:146-149).
Now moving to the medical area which is relevant to the present application, techniques pioneered by Charnley were introduced in the 1960s for the treatment of joint dysfunction utilizing poly(methyl methacrylate) (PMMA) for cementing prosthetic hips (J. Charnley, Lancet, 1961; 1:129-132). The use of PMMA has enabled the successful rehabilitation of many elderly patients with a relatively short life expectancy. However, the inherent polymerization and the presence of methacrylate monomer, is a major factor in the loosening and subsequent failure of hip prostheses (B. F. Kavanagh and R. H. Fitzgerald, J. Bone Joint Surg. 1989; 69A:1144-1149). Despite improvements in bone cement with the introduction of systems based on poly(ethyl methacrylate) and n-butyl methacrylate monomer an ideal bone cement has not yet been produced. For improvements of mechanical strengths of PMMA materials, U.S. Pat. No. 6,312,473 B1 (issued to Y. Oshida, Nov. 6, 2001) discloses that an appropriate amount of metallic oxide powder incorporated with pre-polymerized PMMA beads and polymerizing the mixture with monomer liquid results in increasing mechanical strengths and decreasing undesired temperature rise which might be harmful to living soft tissue.
Development of glass ionomer cements for medical use has, however, fulfilled a clinical need. In otologic and reconstructive surgery increasingly sophisticated surgical techniques require methods of stabilizing implanted devices, bony fragments and reconstruction obliteration of bony defects.
The biological properties of a glass ionomer cement result from its surface chemistry, physical structure and bulk composition. Set glass ionomer cement are essentially hybrid glass polymer composites consisting of inorganic glass particles in an insoluble hydrogel matrix held together by a combination of ionic cross-links, hydrogen bridges and chain entanglements. Setting glass ionomer cements occurs by gelation of the cement with a transfer of ions from the glass to the acidic matrix. In contrast to acrylic cements, this setting reaction does not generate heat and so will not cause thermal damage to tissues at the implant site, or affect heat-labile drugs incorporated into the matrix phase of the glass ionomer cements. Unset glass ionomer cement is able to chemically bond to both bone (apatite) and metals, and during gelation does not undergo appreciative shrinkage. Glass ionomer cement, if used as a bone cement for stabilization of prosthetic implants, would not have to rely exclusively on a mechanical bond to achieve fixation.
Although mechanically inferior to acrylic cements, recent developments suggest that the physical properties of glass ionomer cements can be improved. Glass ionomer cements are, however, ideal for non-weight bearing applications where the ability exists to biomechanically match the glass ionomer cement to the bone. This can be done by varying the volume fraction of the glass and polymer components of the cement (I. M. Brook and P. V. Hatton, Biomaterilas, 1998; 19:565-571).
The clinical success of implanted biomaterials for tissue replacement is dependent upon the formation of a stable bone-implant interface. A pre-requisite for formation of this interface is believed to be the ability of the surface of the material to bind certain biological molecules and attract bone cells. The surface of set glass ionomer cement is hydrophilic, and a more detailed analysis of the surface using X-ray photoelectron spectroscopy shows that it is predominantly organic with trace inorganic species.
It is desirable in implanted materials, where the aim is to establish osseointegration, that the material is able to bind factors that mediate the recruitment and regulation of osteogenic cells. Immunohistochemical studies of implanted glass ionomer cements have shown close association of the non-collagenous extracellular matrix proteins of bone (osteopontin, fibronectin, and tenascin) with the glass ionomer cement surface. These factors, that are known to play an important role in osteogenesis and the osseointegration of biomaterials together with the hydrophilic surface of glass ionomer cement, may explain the osteoconductive properties of implanted glass ionomer cements.
Unlike PMMA bone cement (release of toxic monomer) or ceramic bone substitutes (relatively inert) the main effect that the bulk composition of glass ionomer cement has on their bioactivity is as a reservoir for ion release.
For orthopedic use, the advantages of glass ionomer cement over acrylic-based cements lie in the lack of exotherm during setting, absence of monomer and potential for improved release of incorporated therapeutic agents. The strength of glass ionomer cements as compared to acrylic cements, is a disadvantage in weight-bearing situations. However, the adhesive properties of glass ionomer cements may mitigate this disadvantage. Glass ionomer cements compare favorably with current acrylic-based bone cements in in vitro and in vivo tests, especially when it is remembered that they are in a far earlier stage of development.
Glass ionomer cements are not inert materials but are “bioactive”. Following implantation, an appropriate host response is produced, mediated by the ion exchange, that is composition, site and tissue dependent. Glass ionomer cements can be designed as biocompatible bone substitutes and cements with osteoconductive activity eliciting a favorable biological response and clinical outcome. However, inappropriate use of glass ionomer cements, as with any substance applied to a biological system, can lead to adverse effects. Correct application and surgical technique are essential in order to produce a positive health gain.
U.S. Pat. No. 6,312,473 B1, mentioned above, also discloses that mechanical properties of the cement materials described therein can be improved by incorporating one or more metallic oxide powders in the cement materials.